Title: Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain
1Prehospital Hypertonic Saline Resuscitation of
Patients With Hypotension and Severe Traumatic
Brain Injury
-- JAMA. 20042911350-1357
2Introduction
TBI hypotension (2X)
2nd brain injury
ICP Hypoxia Hypotension
IV fluid
Mortality rate 31-49
Hypertonic saline HTS
8000090000 long term morbidity
Severe traumatic brain injury (TBI)
Major trauma, young adults
3Introduction
- highest survival rates (randomized 4 trial)
- HTS alone, 60
- HTS with dextran 70, 56
- Ringer's lactate solution alone, 49
- HTS-dextron (randomized 8 trial)
- survival from 27 to 38 (adjusted P .048)
4Introduction
Brain trauma foundation
- Guidelines for Pre-hospital
- Management of Traumatic Brain Injury
HTS with or without dextran at the "option" level
decrease secondary brain injury
double-blind, randomized controlled trial
Better neurological outcome ?
5Methods
- December 14, 1998 April 9, 2002
- Melbourne, Australia (4 million persons)
- Paramedics ( by ATLS guideline)
- Adult patients with major trauma
- road ambulance to 1 of 12 hospitals,
- helicopter and road ambulance to a designated
regional trauma center.
6Methods
- Inclusion criteria
- coma due to blunt head trauma,
- GCS lt 9
- hypotension (SBPlt100 mm Hg).
- Exclusion criteria
- penetrating trauma
- lt 18 y/o
- Pregnant
- no iv access
- serious premorbid disease
- peripheral edema
- absent sinus rhythm, or cardiac arrest.
7Randomization and Study Protocol
- 7.5 saline (HTS) / Ringer's lactate solution
- Patients, paramedics, treating physicians, and
study coordinators were all blinded - When a patient met the eligibility criteria, the
next numbered bag of study fluid was infused - 10-mL/kg intravenous colloid or crystalloid or
repeat dose - After hospital admission, patient care was at the
discretion of the attending physicians and
generally followed the guidelines of the Brain
Trauma Foundation.
8Data Collection and Outcome Assessment
- Data
- baseline characteristics
- admission vital signs
- laboratory data
- significant events after admission
- computed tomography scans were reviewed and
graded for severity by a single neurosurgeon
(J.L.)
9Data Collection and Outcome Assessment
- Glasgow Outcome Score (GOS)
- Dead
- Vegetative
- lower severe disability
- upper severe disability
- lower moderate disability
- upper moderate disability
- lower good recovery
- upper good recovery.
3 ,6m later L.J.M
10Data Collection and Outcome Assessment
- Secondary outcomes
- first ICP and cerebral perfusion pressure (CPP)
- duration of ICP elevation and of inadequate CPP
- worst oxygenation expressed as lowest PaO2/Fio2
ratio - duration of inotropic support and mechanical
ventilation - Functional Independence Measure (range, 1-7)
- Rancho Los Amigos score (range, 1-8)
11Statistical Analyses
- primary outcome measure
- GOSE at 6 months
- Secondary outcome measures
- serum sodium and systolic blood pressure at
hospital admission, - initial measurement of ICP,
- hospital mortality rate,
- GOSE at 3 months.
12RESULTS
13RESULTS
14RESULTS
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18GOSE at 6 months
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21Commends
- neurological outcomes
- identical 6 months after injury
- both study groups received the same prehospital
volume - the ICP was lower when first measured in hospital
in the patients with HTS than in controls. (P
.08), - perhaps because intracranial hypertension is
usually not problematic in the first hours after
TBI
22Commends
- Interpretation of ICP and CPP outcomes is limited
because patients who improved quickly or who died
quickly were unlikely to have ICP measured
23strength
- first randomised prehospital trial of HTS
resuscitation in hypotensive patients with trauma
with severe brain injury - baseline characteristics were well-balanced
between groups - first prehospital resuscitation fluid trial to
measure long-term neurological function as the
primary outcome in patients with TBI.
24limitation
- not combine HTS with dextran
- only 229 patients, 80 power to identify a
1-grade change in the GOS following HTS - study population predominantly (90) included
patients with multisystem trauma